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<meta name="description" content="病例先来看病例吧。前两天接的。患者女，62岁，左下后牙自发痛，夜间痛，冷热刺激痛一天就诊。口内检查，36颊侧颈部有充填物，叩痛（+-），无松动，牙龈未见异常，冷诊剧痛。35叩痛（-），无松动，牙龈未见异常，冷诊同对照牙有感觉。27颊侧探及龋坏，未及髓，叩痛（-），无松动，冷诊一过性敏感，无持续性疼痛。重点怀疑36，拍片吧。片子出来我犹豫了，貌似35根尖问题更大啊！36根尖也有问题。做个热诊吧。用热">
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          <h1 class="post-title" itemprop="name headline">一个“惊险”的病例——谈谈临床思维</h1>
        

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        <p><strong>病例</strong><br>先来看病例吧。前两天接的。患者女，62岁，左下后牙自发痛，夜间痛，冷热刺激痛一天就诊。口内检查，36颊侧颈部有充填物，叩痛（+-），无松动，牙龈未见异常，冷诊剧痛。35叩痛（-），无松动，牙龈未见异常，冷诊同对照牙有感觉。27颊侧探及龋坏，未及髓，叩痛（-），无松动，冷诊一过性敏感，无持续性疼痛。<br>重点怀疑36，拍片吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0186-cliniccase/01.png"><br>片子出来我犹豫了，貌似35根尖问题更大啊！36根尖也有问题。做个热诊吧。用热牙胶棒做热诊，从34做起，34反应正常，35热诊即发生剧痛，接着再做36，感觉有不适但不像35那么明显！那就是35的问题喽。于是跟患者谈治疗方案和价格。签字画押后准备打麻药了，我盯着全景片又纠结了，这35没有明显的牙体问题呀。根尖的“暗影”会不会是颏孔啊？<br>于是我决定再拍个CBCT。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0186-cliniccase/02.png"><br>35根尖的确有暗影，颏孔开口区在其下方。再看看36。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0186-cliniccase/03.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0186-cliniccase/04.png"><br>近远中根都有暗影，颊侧充填体影像近髓（这个倒不一定，有可能是伪影）。貌似36问题更大？再做一次热诊吧。这次先做36，结果诱发剧痛，然后做35，疼痛不明显。于是决定开36，同时告知患者，35也有问题，不排除今天开了还是痛，要根管治疗35。患者同意。<br>碧兰局部浸润麻醉下开髓，揭顶，玻璃离子封无砷失活。第二天电话回访，说不痛了。<br>这个病例蛮惊险，要是当时开了35，但是疼痛不缓解，即便35也是应该治疗的，我也很难解释啊。</p>
<p><strong>讨论</strong><br>下面就借这个病例谈谈临床思维的问题吧。先抄一个百度百科的解释：临床思维是指运用医学科学、自然科学、人文社会科学和行为科学的知识，以患者为中心，通过充分的沟通和交流，进行病史采集、体格检查和必要的实验室检查，得到第一手资料，结合其他可利用的最佳证据和信息，结合患者的家庭和人文背景，根据患者的症状等多方面信息进行批判性的分析、综合、类比、判断和鉴别诊断，形成诊断、治疗、康复和预防的个性化方案，并予以执行和修正的思维过程和思维活动。<br>简单的说，所谓临床思维就是通过各种途径从获取疾病的相关的信息，结合医生的医学知识和经验，得到对疾病正确的诊断，从而制订正确的治疗方案的过程。其中最重要的我认为有两个：一个是获取信息，二个是对信息进行判断鉴别形成正确的诊断。<br>诊断思维过程如下：<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0186-cliniccase/05.png"><br>收集治疗获取信息是形成正确诊断的基础，我们要尽可能多的收集一切疾病相关的信息。包括应用各种辅助诊断手段，比如这个病例里的全景片、CBCT、热诊等手段。这就要求医生首先要会选择正确的辅助诊断手段，要知道各种诊断手段能提供什么样的信息，对正确诊断有何帮助，有何局限性等等。其次，还要求医生正确的操作，如正确的拍片，正确的进行冷热诊等，这样才能获取到准确的诊断信息。<br>在获取了足够的诊断信息以后，就要对这些信息进行加工处理，去伪存真，形成正确的诊断。在这个过程中，可能会综合使用演绎法，排除法等各种方法。由于每种诊断手段都有其局限性，都不可能100%准确，如果只依赖某一种诊断手段的结果就得出结论，往往会被误导。要综合各种可能的诊断手段的结果，几个结果互相对比印证。根据概率论的原理，某种诊断手段可能有10%的错误结果，那么两种诊断手段都出错的概率就是0.1×0.1=1%，三种诊断手段都出错的概率就是0.1%，以此类推，就可以大大降低受错误信息误导导致误诊的概率。而当几种诊断手段的结果之间有冲突的时候，就要仔细思考，排除错误的结果，或者进行更进一步的检查。<br>比如上面这个病例，患者自发痛，夜间痛，冷热刺激痛来就诊，我第一个考虑就是急性牙髓炎，然后根据患者指示的牙位找病灶牙（但是也不能完全依赖患者指示，尤其上下颌，我碰到过一直坚称是下颌牙疼，最后检查发现是上颌牙牙髓炎的）。选择拍片，发现35,36根尖都有问题，但是全景片上是35的低密影更大。之后进行热诊，由于两颗可疑病灶牙挨着，第一次做热诊的时候35的反应更剧烈，再结合全景片表现，拟诊断35的急性牙髓炎并准备开髓。<br>这个时候一定要多一个心眼，多质疑一下自己的诊断。我想到了两个问题：第一，35并没有明显的牙体病变；第二，下颌管常在4,5之间通过颏孔开口于颊侧下颌骨，拍的是二维的全景片，那个“暗影”会不会是颏孔的影像重叠？于是决定再收集更多资料以检验自己的诊断，拍了CBCT，基本排除了颏孔影像重叠的问题，35根尖的确有低密影。但是36的根尖也有低密影，而且36有牙体的情况：颊侧颈部的大面积充填物。于是我决定再做一次热诊，先做36。结果发现36疼痛也很剧烈。而做35的时候却反应不明显。<br>纠结了一下，最后决定诊断36急性牙髓炎，局麻开髓。但是并不排除35也有问题，也跟患者交代了。最后治疗结果证实患者就诊的疼痛病灶牙的确是36。从这个病例上我得到两个经验（或者教训）：一定不要仅凭某个单一的证据做诊断，一定要多个证据互相印证；当证据之间互相有矛盾的时候，仔细检查证据是否有错误，考虑证据的局限性（如热诊，患者可能反应有错误，医生操作也可能有错误，导致假阳性或假阴性结果。最好多做几次），收集更多的证据；当还是不能确定诊断的时候，别动手。<br>在网上看了《临床思维与分析能力》的课件，虽然我们口腔科医生的诊断相对大临床的同行来说要简单很多（如果不算口腔颌面外科的话），临床常见的疾病就那么几个。但还是会有误诊漏诊的问题，所以我们牙医也要加强临床思维的训练。平时大家学习往往都集中在具体操作技能的训练上，可能对这一块不太重视。大家共勉吧。</p>
<p>参考文献：</p>
<ol>
<li>百度百科临床思维词条. <a target="_blank" rel="noopener" href="https://baike.baidu.com/item/%E4%B8%B4%E5%BA%8A%E6%80%9D%E7%BB%B4">https://baike.baidu.com/item/%E4%B8%B4%E5%BA%8A%E6%80%9D%E7%BB%B4</a></li>
<li>中山大学附属第三医院《临床思维与分析能力》课程课件.  <a target="_blank" rel="noopener" href="https://wenku.baidu.com/view/e9f4e184f02d2af90242a8956bec0975f465a4c4.html">https://wenku.baidu.com/view/e9f4e184f02d2af90242a8956bec0975f465a4c4.html</a></li>
</ol>
<p>我发文章的四个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的博客园博客地址： <a target="_blank" rel="noopener" href="https://www.cnblogs.com/zwdnet/">https://www.cnblogs.com/zwdnet/</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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